simple

1. Screening for Critical Congenital Heart
Defects with pulse oximetry:
UK perspective
Andrew Ewer
Professor of Neonatal Medicine
University of Birmingham UK
Neonatologist, Birmingham Women’s Hospital

2. Pulse oximetry screening
Rationale
Hypoxaemia (low saturations) present in the
majority of critical CHD (CCHD)
Frequently clinically undetectable
Pulse oximetry may detect babies with CCHD
early, before they collapse

3. Pulse oximetry screening
• 8 studies - 35 960 patients
• Small numbers of patients, low prevalence of CCHD,
methodological variations
• More high quality studies (in larger study populations)
needed to precisely define test accuracy

4. Pulse oximetry studies
2009 - 2012

5. Pulse oximetry studies
2009 - 2012
• Granelli – Sweden, (BMJ 2009) [>24 hrs, Pre/post ductal]
• Riede – Germany, (EJP 2010) ) [>24 hrs, Post ductal only]
• Ewer – UK, (Lancet 2011) ) [<24 hrs, Pre/post ductal]
• Turska−Kmieć – Poland, (Kardiologia Polska 2012)
[<24 hrs, Post ductal only]

6. Detection of significant non-cardiac disease an
important additional finding in all studies
(28-70% of false positives)

7. Further work
Pulse oximetry screening
• Is acceptable to parents and staff
• Anxiety not increased in false positives
• Is cost-effective in an NHS setting

8. 13 studies 229 421 patients (c.f. 8 studies, 36 000 pts)
Overall sensitivity 76.5% (95% CI 67.7% - 83.5%)
Overall specificity 99.9% (99.7% -99.9%)
False positive rate 0.14% (0.06 - 0.33)
(FPR <24 hrs 0.5%. FPR >24 hrs 0.05%)
(Did not include full Polish study)
2nd May 2012

9. …surely the question now is not ‘should pulse
oximetry screening be introduced?’ but ‘why
should such screening not be introduced more
widely?’
Lancet 2012;279:2401.

10. April 2014
• 120 707 babies screened
• Pre and post-ductal saturations
• Sensitivity for CCHD – 83.6%
• False positive rate 0.3%

11. ‘Further trials are unnecessary. Now is the time for
professional bodies to review the evidence and
consider a pulse oximetry screening protocol that
best suits their requirements’
Ewer AK. Lancet 2014;384:725-6.

12. How should screening be done?

13. Screening protocols
• Pre and post or post-ductal only?
• Early or late screening? (<24 hrs or >24 hrs)

14. Pre and post-ductal vs Post-ductal
• No difference in sensitivity in meta-analysis
• Pre/post consistently identifies CCHD which would
have been missed by post-ductal
Granelli – 1 CCHD
Ewer – 3 CCHDs
Equivalent to 7 CCHDs per 100 000 births

15. Early or late screening
(<24 or >24hrs)
• Most babies have ‘normal’ sats within 12 hr
• FP lower if PO screening >24 hr
0.05 vs 0.5%

16. CCHD presenting before screening
• Later screening studies report 50% of CCHD
babies presented before screening1,2
Up to 10% present with collapse in hospital 1
1. Granelli BMJ 2009
2. Riede EJP 2010

17. CCHD presenting before screening
• New Jersey experience – 2011 -2012
72 694 babies screened –
FP rate 0.04% but only 3 CCHDs identified1
• Not specified but likely many CCHDs presented
before screening (70-140 CCHD expected)
1. Garg et al Pediatrics 2013

18. • BWH screening programme
2010-2013 (40 months)

19. • Total Livebirths: 25 859
• Most babies screened <12 hrs (mean age 7 hrs)
• Test positive pulse oximetry: 208
0.8% of all livebirths - Just >1 admission a week
Congenital heart defects identified: 17
– Critical CHD: 9 [+2FNs]
– Serious CHD: 3
– Significant CHD: 5
55 pneumonia, 30 sepsis, 12 PPHN. Only 43 (21%) were healthy (True FPs)
Singh, Rasiah, Ewer Arch Dis Child FN 2014;99:F297-F302.

20. Echocardiograms
• Echos performed for test +ve pulse Ox:
61/208 (29%)
• Abnormal Echos: 29/61 (48%)

21. Murmurs and echocardiography
• 3 year data from Birmingham Women’s Hospital
• 205 echos for babies with murmur
• 123 (60%) no significant abnormality
• 72 (35%) septal defects
• 2 (1%) CCHD – 1 CCHD/100 scans
• [PulseOx 9/61 (15%) CCHD] – 1 CCHD/6.5 scans
Singh A et al. Acta Paed 2012;101:1651-2227.

22. False positives
Need to consider trade off between
false positive rate and timely diagnosis
Also…
Earlier diagnosis of respiratory/infective cases
Increasing discharges within 24 hours
False positives are babies with low oxygen levels
No baby should have unexplained persistent hypoxaemia

25. UK pilot - Methods
15 acute Hospitals participated over 6 months
1st Jul 2015 – 31st Dec 2015
- rural MLU to tertiary centres (incl. homebirths)

26. 26
Newborn Pulse Oximetry Screening Pilot Stakeholders Meeting
UK Newborn Pulse
Oximetry
Screening Pilot
Pathway

27. US algorithm UK algorithm

28. UK pilot
• 32 836 babies screened
• 239 test positives (0.73%)
• 14 CHD (8 CCHD) – [2 FNs]
• 82 significant non-cardiac disease

29. PO screening vs. Hearing screening
UK experience - screening well babies
Hearing* PulseOx(BWH) PulseOx(UK)
Referral rate 2.2% 0.8% 0.73%
Target condition pick-up** 7 3.4 2.4
False positives† 213 80 70
**Per 10 000 tests (60 w/ sig. illness) (25 w/ sig. illness)
*Wood, Sutton & Davis. Int J Audiol 2015;54:353–8

31. Summary
• Pulse oximetry screening is feasible, acceptable,
cost-effective and reduces the diagnostic gap for
CCHD.
• Most appropriate algorithm is likely to be refined
with national input from national datasets and may
be adjusted according to local circumstances

32. Reviews and commentaries
• Ewer AK. How to develop a business case to establish a neonatal pulse oximetry screening
programme for screening of congenital heart defects. Early Hum Dev. 2012;88:915-9.
• Ewer AK. Review of pulse oximetry screening for critical congenital heart defects. Current
Opinions in Cardiology 2013;28:92-6.
• Ewer AK. Pulse oximetry screening for critical congenital heart defects. Should it be routine? Arch
Dis Child Fetal and Neonatal Ed 2014;99:F93-F95.
• Ewer AK. Pulse oximetry screening: do we have enough evidence now? Lancet 2014; 384: 725-
26.
• Ewer AK. Evidence for CCHD screening and its practical application using pulse oximetry. Early
Hum Dev 2014;90:suppl 2 S19-21.
• Narayen IC, Blom NA, Ewer AK, Vento M, Manzoni P, te Pas AB. Aspects of pulse oximetry
screening for critical congenital heart defects: when, how and why. Arch Dis Child Fetal
Neonatal Ed 2016;101:F162-F167.
• Ismail AQ, Cawsey M, Ewer AK. Newborn pulse oximetry screening in practice. Arch Dis Child
Educ Prac Ed. 2016 Aug 16. doi:1136/archdischild -2016-311047. [Epub ahead of print].
• Ewer AK Pulse oximerty screening for critical congenital heart defects: medical aspects. Am J
Perinatol 2016;
• Ewer AK, Martin GR. Newborn pulse oximetry screening: which algorithm is best? Pediatrics
2016;138(5):e 20161206.
a.k.ewer@bham.ac.uk

33. CONCLUSION
Pulse oximetry is a safe, non-invasive, feasible, and reasonable
accurate test, which has a sensitivity that is better than that of antenatal
screening and clinical examination.
•adds value to existing screening procedures and is likely to be useful
for identification of cases of critical congenital heart defects that would
otherwise go undetected.
•The detection of other diseases such as significant congenital heart
defects, and respiratory and infective illnesses is an additional
advantage.
•Potential benefits of the introduction of pre-discharge pulse oximetry
screening as a routine procedure.

34. conclusion
Various studies and review articles all over the globe have suggested
the usefulness of pulse oximetry screening for detecting the congenital
cardio vascular malformations in asymptomatic new-borns.
However, very little research has been done in this particular field
in our country.
These studies adds to the evidence in support of starting the pulse
oximetry as a routine neonatal screening programme to let many a
children to live a long life with healthy hearts.